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Chapter 20

allowed charge (allowable amout) The maximum amount of money that many third-party payers allow for a specific procedure or service
authorization An alphanumeric/number given by the insurance company authorizing approval of a procedure or service. This does not guarantee payment
beneficiary The individual entitles to receive benefits from an insurance policy or program or a governmental entitlement program offering healthcare benefits. Also called a participant, subscriber, dependent, enrollee, or member
benefits The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage
birthday rule An insurance rule that applies as follows: when an individual is covered under two insurance policies, the insurance plan of the policyholder whose birthday comes first in the calendar year (month and day, not year) becomes the primary insurance
capitation A payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for patients enrolled during a specific period of time, no matter what service were received or how many visits were made.
carriers In insurance terms, companies that assume the risk of an insurance policy
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) See TRICARE
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Health care program in which the VA pays the cost of covered services and supplies for eligible beneficiaries;, the individual cannot be eligible for TRICARE, but can be the spouse of child of a disabled vet, surviving spouse or child of vet who died from
co-insurance A policy provision frequently found in medical insurance whereby the policyholder and the insurance company share the cost of covered losses in a specific ratio (ie 80/20 means that 80% is covered by the insurer and 20% is covered by the insured)
commercial insurance plans Plans that reimburse the insured for expenses resulting from illness or injury according to a specific fee schedule as outlined in the insurance policy and on a fee-for-service basis. Sometimes called private insurance.
co-payment A sum of money that is paid at the time of medical service, a form of co-insurance
deductibles Specific amounts of money a patient must pay out of pocket before the insurance carrier begins paying. Usually this amount ranges from $100 to $500. This deductible amount is met on a yearly or per-incident basis.
dependents The spouse, children, and sometimes domestic partner or other individuals designated by the insured who are covered under a healthcare plan.
disability income insurance Insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.
effective date The date on which an insurance policy or plan takes effect so that benefits are payable
eligibility A term that describes whether a patient's insurance coverage is in effect and eligible for payment of insurance benefits.
exclusions Limitations on an insurance contract for which benefits are not payable
explanation of benefits (EOB) A letter or statement from the insurance carrier describing what was paid, denied, or reduced in payment. It also contains information about amounts applied to the deductible, the patient's co-insurance, and the allowed amounts
explanation of Medicare benefits (EOMB) An explanation fo benefits from Medicare
fee for service An established schedule of fees set for service performed by providers and paid by the patient
fiscal intermediary An organization that contracts with the government to handle and mediate insurance claims from medical facilities, home health agencies, or providers of medical services or supplies.
government plans Entitlement programs or healthcare plans that are sponsored and/or subsidized by the state or federal government, such as Medicaid and Medicare
grandfathered A legislative provision that allows the exception based on a preexisting condition
group policy Insurance written under a policy that covers a number of people under a single master contract issued to their employer or to an association with which they are affiliated.
guarantor The person responsible for paying the medical bill
Individual policy Insurance type that is often purchased when a person does not qualify for inclusion in a group or government-sponsored plan
TRICARE Provides healthcare coverage for dependents of military personnel
Self-insured plan A type of insurance in which the employer pays employee healthcare costs from the employers own fund
Disability protection insurance Insurance that provides weekly or monthly cash benefits to policyholders who become unable to work as a result of an accident or illness
Major medical insurance Insurance that provides protection against especially large medical bills resulting from catastrophic or prolonged illnesses
Basic medical Insurance that pays all or part of a physicians fee for nonsurgical services including hospital, home and office visits
Health Maintenance Organization (HMO) provides a wide range of healthcare services for a specific group at a fixed periodic payment. HMOs can be sponsored by government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies and hospital-medical plans.
Indemnity plans traditional health insurance plans that pay for all or a share of the cost of covered services, regardless of which physician, hospital, or other licensed healthcare provider is used.
Individual policy insurance policy designed specifically for the use of one person and his or her dependents, An individual policy generally does not offer some of the amenities of a group policy (ie: lower premiums)
Managed care plans An umbrella term for all healthcare plans that provide healthcare in return for preset monthly payments and coordinated care through a defined network of primary care physicians and hospitals.
Preauthorization A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services or refer a patient to a specialist.
Premium The periodic payment of a specific sum of money to an insurance company for which the insurer in return agrees to provide certain benefits
remittance advice (RA) An explanation of benefits from Medicaid
resource-based relative value scale (RBRVS) fee schedule designed to provide national uniform payment of Medicare benefits after adjustment to reflect the differences in practice costs across geographic areas
rider special provision or group of provisions that may be added to a policy to expand or limit the benefits otherwise payable. It may increase or decrease benefits, waive a condition or coverage, or in any other way amend the original contract
self-insured (or self-funded) An insurance plan funded by an organization having a large enough employee base that it can afford to fund its own insurance plan
service benefit plans Plans that provide benefits in the form of certain surgical and medical services rendered rather than cash. A service benefit plan is not restricted to a fee schedule.
third-party payers Entities that make payment on an obligation or debt but are not parties to the contract that created the debt
Utilization review review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources
Created by: brandydenton
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